Endolymphatic shunt

Definition

An endolymphatic shunt is a surgical procedure in which a very small
silicone tube is placed in the membranous labyrinth of the inner ear to
drain excess fluid.

Purpose

An endolymphatic shunt is placed as part of the treatment of
Ménière's disease, a disorder of the inner ear whose
causes are still unknown. Ménière's disease is
characterized by the following symptoms:

a rise in the level of endolymphatic fluid in the labyrinth of the inner
ear

hearing loss that comes and goes

a sensation that the environment or oneself is revolving or spinning
(vertigo)

ringing, buzzing, or hissing noises in the ears (tinnitus)

a feeling that the ears are blocked or plugged

Endolymphatic shunt surgery is one of the surgical procedures available to
treat Ménière's disease, which is
also known as endolymphatic hydrops. The surgery is based on the theory
that the disorder causes the inner ear to become overloaded with fluid and
that draining this fluid will relieve the symptoms. The fluid is drained
by opening the endolymphatic sac, a pouch located next to the mastoid bone
at the end of the endolymphatic duct. The endolymphatic duct is a canal
that leads to the inner ear.

Demographics

According to the National Institute on Deafness and Other Communication
Disorders (NIDCD), there were an estimated three to five million cases of
Ménière's disease in the United States in 1998, with
nearly 100,000 new cases diagnosed annually. In most cases only one ear is
affected, but as many as 15–40% of patients are affected in both
ears. The onset of Ménière's disease occurs most
often in adults between the ages of 20 and 50. Men and women are affected
in equal numbers.

Description

An endolymphatic shunt is placed with the patient under general
anesthesia. The operation takes about two hours to perform. The patient is
usually positioned lying on the back with the head turned to one side and
the affected ear lying uppermost. The head is immobilized and supported
with a pad or brace. The operation itself begins with opening the mastoid
bone and identifying the endolymphatic sac. To find the sac, the surgeon
removes the bony cover of the sigmoid sinus, which is an S-shaped cavity
behind the mastoid bone. The surgeon leaves intact a small rectangle of
thin bone called Bill's Island (named for Dr. William House). The
sigmoid sinus is then collapsed with gentle pressure. The surgeon exposes
the endolymphatic sac and makes an incision in it in order to insert the
shunt.

Diagnosis/Preparation

The diagnosis of Ménière's disease is based on the
patient's medical history, a
physical examination
, and the results of hearing tests, balance tests, an electronystagmogram,
and imaging studies. An MRI or CT scan is performed to rule out a tumor as
the cause of the patient's symptoms. A hearing test (audiogram)
identifies the hearing loss that is typical of
Ménière's disease. Balance function tests are
administered to assess the patient's vertigo.

The patient is prepared for surgery by having the hair removed and the
skin shaved over an area of at least 1.5 in (3.8 cm) around the site of
the incision. A mild solution of soap and water is commonly used to
cleanse the outer ear and surrounding skin.

Aftercare

The operated ear is covered with a Glassock dressing, which is a special
dressing applied to keep pressure on the site to reduce swelling. There is
usually some tenderness and discomfort in the operated ear and the throat
(from the breathing tube inserted during surgery), which can be controlled
by such analgesic medications as meperidine (Demerol) or oxycodone
(Percocet).

Risks

There are few risks associated with endolymphatic shunt surgery. The
operation is considered the first-line surgical treatment for
Ménière's disease precisely because it is very safe.
The chance of hearing loss from the procedure is about 0.5%.

Normal results

Endolymphatic shunt surgery relieves the vertigo associated with
Ménière's disease, with restoration of hearing
dependent on the severity of the disease. The patient's ear may
protrude slightly shortly after surgery but usually returns to its
original position within two to three
weeks after the operation. Numbness around the ear is a common
complication that may last for several months.

Morbidity and mortality rates

Endolymphatic shunt surgery is considered a lowmorbidity procedure. It has
been reported to achieve complete or substantial control of vertigo in 81%
of patients, with significant improvement in hearing in about 20%.
Overall, there is a 60% chance of curing the vertigo, a 20% chance that
the attacks will remain at the same level of severity, and a 20% chance
that the attacks will get worse. The patient's vertigo usually
improves even if hearing does not improve.

Alternatives

Nonsurgical alternatives

There are several nonsurgical treatments recommended for patients with
Ménière's disease:

Vestibular suppressants. These are drugs designed to control vertigo
attacks; they include mechzine (Antivert), diazepam (Valium), and
dimenhydrinate (Dramamine).

Diuretics. Medications that increase the body's output of urine
can also help reduce the frequency of vertigo attacks in some patients
by lowering the amount of fluid in the body.

Dietary changes. Although the benefits of a low salt diet have not been
confirmed by formal scientific research, many patients with
Ménière's disease have noted that their symptoms
improve when they restrict their salt intake.

Steroids. Prednisone and other steroids have been used to treat patients
in the early stages of Ménière's disease. Their use
in this disorder, however, is still considered experimental as of 2003.

Surgical

Surgical alternatives to the placement of an endolymphatic shunt include:

Selective vestibular neurectomy. In this procedure, the surgeon cuts the
vestibular nerve, which relays balance, position and movement signals
from the inner ear to the brain. Vestibular neurectomy prevents the
transmission of faulty information from the affected ear and eliminates
attacks of vertigo in many patients.

Labyrinthectomy. In this procedure, the membranous labyrinth of the
inner ear is removed. Labyrinthectomy is more successful than other
surgeries in eliminating vertigo, but the patient suffers complete and
permanent loss of hearing in the operated ear.

Resources

books

Graham, M. D.
Treatment Options for Ménière's Disease:
Endolymphatic Sac Surgery: Do It or Don't Do It and Why?
San Diego: Singular Publishing, 1998.

other

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An endolymphatic shunt is performed in a hospital or ambulatory surgery
center on an outpatient basis. It is done by an otolaryngologist, who is a
surgeon specializing in disorders of the ear, nose, and throat.

QUESTIONS TO ASK THE DOCTOR

What are the alternatives to an endolymphatic shunt procedure?

Will I regain my hearing if I have this surgery?

Can I expect improvement in any of the other symptoms of
Ménière's disease?

User Contributions:

I have a suggestion for an additional question to add to "Questions to ask the Doctor"; how long can a patient expect to enjoy the benefits of this procedure?

I am asking this because I don't know what either the answer or the estimate might be. In my case I had and Endolymphatic Sac Decompression performed (Graduate, Phila) in 1997, and in 2003 the symptoms returned in one complete and exacerbated instant.

My suspicion is that this happened because of an acute diuretic exchange in my body while I slept - although I was waking when I felt the onset of fullness and hyperamplified tinnitus. I also believe that the shunt is clogged or entirely displaced. I would welcome any comments about my own guess-work. I have a follow-up appointment scheduled (this after giving up on clincal mitigation the problem over 18 months ago). I intend to ask for an MRI on both my affected ear and on my good ear to compare the size of the Sac (albeit the affected ear has already been altered by the existing shunt). After reading this article I think that my own issue is a maintenance problem more than a degradation of the ear itself...?

My husband just had this surgery and we are waiting to see whether his symptoms are relieved. But our surgeon said he has only had to do this surgery twice on one patient because scar tissue had built up around the shunt so he had to go in and replace it. This happened after 10 years. Good luck!

Yesterday while driving home in the evening traffic, a sudden attack of vertigo came on really hard and fast. I managed to make it off the road. It lasted about a minute. I had the shunt operation about 6 years ago.
Has this happened to anyone else out there?
Please God, no more vertigo...

I had a shunt operation 5wks ago. Thank God so far no vertigo attacks only mild dizziness a couple of times. My problem is that my ear still feels full and my head echos whenever I talk
or sing. Small problem I know compared to the bad vertigo attacks I use to have.
Will this fullness and echoing go away?

Where can I locate surgeons in the Philadelphia area. Can someone provide me with a list. What is the down time for this surgery, inasmuch as not being allowed to work outside the home, etc. I am 61 years old, and employed full-tim. I watch my salt intake, am taking effexor, and the lowest dose of Valium. I have dizzy spells AND spinning sensations that were somewhat controlled after balance therapy about a years and a half ago. I was leaving my position, the horrible spinning sensation came over me, my car left the road and hit a tree, totally my car, but I was not hurt only my chest from the seatbelt tightness. The original doctor that I was led to who came to me highly in enter city Phila. never mentioned this surgery, but did mention Gentamyacin injection. Can someone please lead me to the best doctor in Philadelphia who performs endolymphatic surgery. Thank you.

Where can I locate surgeons in the Philadelphia area. Can someone provide me with a list. What is the down time for this surgery, inasmuch as not being allowed to work outside the home, etc. I am 61 years old, and employed full-tim. I watch my salt intake, am taking effexor, and the lowest dose of Valium. I have dizzy spells AND spinning sensations that were somewhat controlled after balance therapy about a years and a half ago. I was leaving my position, the horrible spinning sensation came over me, my car left the road and hit a tree, totally my car, but I was not hurt only my chest from the seatbelt tightness. The original doctor that I was led to who came to me highly in enter city Phila. never mentioned this surgery, but did mention Gentamyacin injection. Can someone please lead me to the best doctor in Philadelphia who performs endolymphatic surgery. Thank you.

I had this procedure done by a specialist in Houston, Texas 5 weeks ago. So far, nothing good to report. I am still recovering. He has me on fluid pills and prescribed me a compound called Transderm. I rub a bit on the inside of each wrist in the morning and at bedtime. I still get the Vertigo symptoms, but I can usually end it by focusing on something specific until the spinning stops. I can say, though, that he told me recovery would be about 1 week and it's been 5 weeks and I'm still unable to walk straight or do anything by myself. AFTER the surgery he told me that 4-6 weeks recovery is not uncommon. My original doctor never mentioned that there were procedures that might help. I was very happy to find a doctor in Houston. It was outpatient and I spent the night in a nearby hotel. Hopefully within another week or so, I will be back to normal with a whole lot less of those horrible, debilitating attacks!!

After two months of Vertigo, Docs finally stopped calling it an ear infection and did further tests which resulted in my diagnosis. I haven?t found a good remedy, although if I am not stressed or tired or doing a lot of travel, I don't experience it that much.
http://www.thebrainhealth.com/what-is-vertigo.html

I am scheduled for the shunt surgery next week on my right ear,then later on the left ear. In all that I have read I don't find where the shunt drains the fluid, does it go down the throat or some other way?
I have also begun having pain and pressure in my right eye. The Dr says this would not be related to Menier's disease. My eye doctor checked my field of vision and said it was limited, but the neuro-ophthalmologist says my field of vision is fine. He has given me neuroton to deal with the pain, but the pressure remains. Has anyone else had similar issues?

My wife read somewhere that people can have throat problems after the shunt surgery. Is this a risk and what kind of potential problems can occur? I have just regained my voice after sever GERD and finally had surgery last year for it. My speaking voice has returned, but still does not have good duration or stamina, so I am hoping this surgery will not set me back. Unfortunately I am still not able to sing, which is a great frustration.

i have been surfering with meniere disease for 10yrs now i have gone to several doctors in nigeria but no result. i am fed up i need a doctor who can perform this surgery effectively. please i need help thanks

Hello, I am 29 years old and have been suffering from this disease for 11 years and am a mom of two young kids. Has anyone ever tired the Minette device? I have had a shunt that worked for about 5 years, just had a revision two months ago and am getting no relief.I am thinking of going to a place in la called House of Ear anyone ever been there. Any advice is greatly appreciated. Talking about brain surgery next to cut the nerve and I am not sure thats the path I want to go down.Way to many risks.

I had Endolymphatic Subarachnoid surgery on my left ear at St. Vincent's Hospital in Los Angeles in 1978. Dr. Brackmann of House Medical Clinic performed the surgery. While it took approximately a year for my system to settle down and adjust, I have had more than substantial relief from severe vertigo. The surgery did not help my hearing to return and I have, in fact, lost hearing in both my ears.

As far as I can tell, after over 30 years since surgery the shunt is still working. I do suffer from bi-lateral severe-classicMeniere's Disease. I had all three main symptoms to a major degree. I was diagnosed in 1977, with suggestion that the disease may have started in my early childhood.

I awakened to a severe vertigo attack in 1985 and was subsequently diagnosed with Meniere's disease in my right ear by Dr. John House, House Clinic, Los Angeles. My mother had been diagnosed with it in 1964 by Dr. William House. I had few serious vertigo episodes and controlled mild to moderate chronic and seasonal vertigo with diet and medication for several years. In 2006, for reasons unknown severe vertigo episodes began again and caused substantial interruption sufficient to require me to stop working and go on disability. Dr. House advised surgery but I elected to wait, hoping for a spontaneous remission. The vertigo episodes continued and the hearing in my right decreased from 92% to 33% during that year. In August 2009 Dr. House performed the endolymphatic shunt surgery at St. Vincent's Medical Center, and while my hearing did not improve, the severe vertigo ceased. Only occasional transient, very mild vertigo occurred until August 2011 when the severe vertigo episodes began again. After steroid treatment and other tests, Dr. House suggested a revision of the shunt. I had the surgery two days ago on December 6, 2011 and remain hopeful that this surgery will be successful indefinitely.

Because vertigo is so immediately debilitating, the long term effects of repeated attacks sometimes go unnoticed for quite a while. The fear of having a serious attack, of being incapacitated abruptly, without warning, can cause lifestyle changes that shrink one's world significantly. If you suffer from Meniere's induced vertigo, I encourage you to consider the shunt surgery. While I have had a revision surgery, the time free of the vertigo was wonderful and I remain hopeful that the second surgery is and will remain successful. I feel fortunate to have viable treatment from Dr. John House, a dedicated, skilled and talented doctor.

I had the shunt surgery one week ago. Left hospital hearing fine. Two days later ear is feeling full and continues. Have had severe vertigo episodes and feeling they will return. Question for others who have had this, will fullness go away? Feelind depressed as I thought surgery would cure problem.

I found out I had Meniere's in May after several severe episodes of vertigo which began in January. Most of the time I recovered from these within a couple of days. I have tried steriods, I'm on a fluid pills and have drastically adjusted my diet. The last episode at the end of July was the worst and it took almost two weeks to feel "normal" again. Even still I have fullness, ringing and dizziness. I went to a specialist in Chapel Hill NC and he has recommended the surgery. I am waiting for this to be scheduled. My prayer is that it will give me a level of comfort and ability to live without fear.

Respected sir, Iam 40 years old. I am suffering from Meniars disease from last 15 years. Present I have no vomiting and vertigo,giddiness, I am suffering from hearing loss and continuously noise(sounds) from my both ears. My both ears are hearing loss is 56db. Recently 4 injections has been taken to my inner ear in yasoda hospital, hyderabad.
Will I regain my hearing if I have this surgery?

Yesterday I had a revision to an endolymphatics mastoid shit. The orignal shunt surgery was performed 3 years ago and wthin afeww weeks of the operation the virtigo and "fillneess" feelings were gone. Howveer after this initial period the benefit of teh shnt seemed to lessen until the symtoms retruend to ther earlier levels ro mayb a little worse. The revision surgery found that the mastoid bone had grown over the end of te shunt effectivy "plugging" the shunt. My doctor , sugeon is at NC Chapple hill hospital and I would recommend him to anyone suffering from menier's symdrome. The revision surgery was not very painful and I'm already at home. I see the doctor in about a weeks time for a post0op visit. My hope is to return to work with a2 weeks but I'm very confident in the doctor's advise and intend to follow it to the letter. I hope this helps allivate some of the anxiety about this operation (especially for you Angela). God bless you.

Pat~ I am a 37 year old who has had bilateral Menieres Disease, it became bad around a year ago, after seeing a number of doctors I was told to go to UW Madison Hospital for more tests, which is when I found out for sure it was Menieres. I was scheduled for my first surgery on July 25th of 2012. It helped greatly in my right ear. After going to my post op visit, I was told I was losing the hearing in my left ear and prior to the appointment I had started to get the vertigo again while I was at work, so I was scheduled to have the surgery on my left ear. The surgery was October 24th 2012, and I had the worse dizziness for quite a few days afterwards. It has been almost 2 weeks, and the right ear which was the ear with the most hearing loss is now my good ear. I have very little hearing in my left ear, hoping it will come back, but with the first surgery my hearing had started to come back within the week, so I am still wondering if I will hear. Having the surgery may not give you your hearing back fully there's a good chance it could stay the same or 0.5% chance you could lose it all together. If you don't have the vertigo, nausea or anything else I would recommend just getting a hearing aid, which is what I will most likely be doing if mine does not come back. I am hoping this helps you? I have gone through it and know what my outcome was, so this is my advice.

I have been diagnosed with Menieres for about 5 years and dealing with it around 9 years before proper diagnosis. I went through diaretics (water pills) which did more harm than good, then they treated me with Klonopin (Clonazepam) which seemed to delay attacks, but not eliminate them. I didn't take long to get to a bad point again with this. The next step was they inserted a tube in my eardrum and I use a Meniett device several times daily while taking the Klonopin at night. This worked extremely well for about 6 months until the tube began to come out. When the doctor tried to adjust the tube they tore my eardrum, patched it, and inserted another tube. Unfortunately after this occurred I am now at my worst point. I am currently having up to 3 or 4 attacks of vertigo daily several times a week. I am now scheduled to have an endolymphatic shunt put in and they are going to remove the honeycomb membrane behind my ear. Hoping this works so I do not have to resort to a vestibular neurectomy which the doctor said is the most evasive and hardest to recover from. Best of luck to all of you out there dealing with this. Here is another good link for support and additional information out there:

I am suffering from MENIARS Disease from last 20 years, present I have not giddiness and vertico etc., only some knows are there and I loose my hearing upto 70db from my both ears. Will I regain my hearing if I have this surgery? and any treatment?

I am getting the EKG and blood work done this week, as soon as my doctor receives it - I will be scheduled for the Endolymphatic Mastoid Shunt Surgery. After reading everyone's posts, I don't know if I should. They will drill behind my ear and then what? Mess me up more. I've have Meneire's 8 years - it is a nightmare I wouldn't wish on anyone. If anyone can tell me something real positive about this, please email me. Thanks.

I usually don't write on boards like this. I'm 33 years old and have been suffering from Menieres Disease for 4 years. The attacks started one day while at work, I became very dizzy and started getting sick. It took several months and several Dr's before I received a diagnosis.

Like many of you, the attacks have become severe and disabling. I'm not able to work and had to stop driving as I'm having attacks driving. I hate this disease, I hate feeling like I have no control. I have recently had the steroid shot in my ear, and did not receive any results from it. In fact, I never complain from any shots but this was different. Apparently, when they put something in your ear it drains to your throat. The shot went into my ear and into my throat. The pain was unbearable. It felt like strep throat of my ear and throat at same time.

I went to Dr yesterday and he told me since it didn't work that he recommended the Endolymphatic sac surgery. the hospital said that Dr didn't have any openings until June 18th. But at last minute they found one this Friday. Gives me the rest of today to not try and stress about it. To be honest it scares me to death.

I guess I'm writing this for myself not sure if anyone will read it. If you do and you are suffering with the disease to I wish you nothing but the best.

I am a 58 year old who had her kidney out from kidney cancer a year ago. Since then I've suffered with severe dizziness attacks and went in the emergency room 4 times so ill. I've been on triamterene, valium, the steroids, and even a patch they put behind my ear which messed me up worse. Also zophran for nausea. I've been bedridden most of the time. I watch my salt intake. I had the steroid shot in my ear a week ago which gave me only a little relief. I'm having the Endolymphatic Sac surgery in a few weeks and am very nervous. I want to be able to drive again and have my life back. It seems that every time my clothes rub against the incision from having my kidney out, which is a huge incision and is still swollen, it effects my meniere's. Does anyone know of a creme that can be rubbed on the incision to help with the pain. I am nervous about the surgery and hope it works. Had surgery a few weeks ago. Had a tumor removed from my other kidney. That one wasn't too bad. So tired of my bed and the spinning.

I had the endolymphatic shunt surgery for meniere's 20 years ago after my vertigo and nausea symptoms became too debilitating. I now need an MRI for another condition and the MRI place is having some difficulty documenting the safety of the MRI without documenting exactly what the shunt is made of. Anyone ever have this problem?

I had the shunt surgery 2 years ago, I had attacks prior at least 3 or more times a month. I was the .05 that lost total hearing in the affected ear after the surgery, however I have not had any attacks (knock on wood). I would do this all over again and be deaf in my left ear compared to the violent attacks, I can lead a "normal" life now and not have the anxiety of when the next attack will occur.

My husband, Antonino Cusma, has been suffering from dizziness and buzzing in his ears for about 3 years. Has had many tests, but the specialist said that he has the labyrinth which is hardened due to age (will be 79 years old this Fall) and has vascular parkinsons and is hypertensive. He said that he will just have to live with it. We live in Italy. Is there someone here in Italy that you know would be the specialist that we can turn to? We would be able to go anywhere in Italy if necessary. I thank you for your time. Most cordially, Josephine Saggio

I also have Menieres Disease. Finally diagnosed after 3 years of dizzy episodes with severe vomiting. This past year it seems to happen monthly now instead of 1 time per year. I have had the antivert, diuretics, valium, and steroids with no help. I've had a CT, hearing test (after hearing test), and balance study. Finally seeing a different doctor I was diagnosed with Menieres and scheduled for December to get the shunt. Seems after reading all the comments it works for a few years? There were some it worked for several years. I pray I am one of those lucky ones. I hate these dizzy/vomiting spells.

I had the shunt surgery 3 months ago. My vertigo is still about the same but unfortunately all of any useful hearing was lost. Before the surgery I had full hearing. The doctor says it is too late and permanant. Total loss of hearing was not part of the plan. Some small part of me thinks it is still swollen and healing but i guess thats wishful thinking. I only have hearing in the high frequencies.

surgery suggested after nearly four years, three Docs. Numerous test, tubes, pills, diets changes, hearing aid, sound training. Still sitting in a room by myself. Driving my self and everyone around me batty with requests to adjust volume to accommodate my ear. Constantly hurts, feel pressure on side of head, rings, voice resonates when I talk.Can't raise my voices with out feedback, can't move head with out causing another noise within ear. humming cycling on top of ringing and feedback. Exhausted, can't remember the simplest thing with all of the distraction. Not working. Not sure that surgery is the answer, ready to unhook ear altogether. Serves no purpose other that a poor connection, balance, filter, can't process more than one sound input at once. Do not want to a habit of surgeries.Just want to do the right one and be done with this nightmare before I end up in a room alone for life!

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